Appointment checklist

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1 Appointment checklist Credit, Budget, Post-Purchase Please bring the following documents to your appointment: Completed appointment packet (enclosed) Driver s license or other photo ID AND Passport or Birth Certificate Verification of all household income (one month s worth of pay stubs for each job, profit and loss statement if self-employed, benefits award letter, etc) Credit Report(s) if you would like to review them. See the enclosed page with instructions for ordering your free annual credit reports. If you are refinancing a home or wish to discuss rehab loans: Please bring the loan documents from your lender, including: Good Faith Estimate, Truth in Lending Disclosure, and HUD 1003 Loan Application Please bring a copy of your most recent current mortgage loan statement(s) If you would like to discuss debt reduction: Please bring a list of your current creditors with balances owed, interest rates being charged, and monthly payment for each debt It is necessary to complete this packet prior to your appointment, so that we can best utilize our time and provide individualized service to you. The appointment may need to be rescheduled if this packet is not complete. 1 P a g e

2 Housing Counseling Program Intake Form Please print clearly. Information will not be shared with any third party without your explicit signed authorization. Household Information Last Name: First Name: Street Address: City: State: Zip: County: Home Phone: Last four digits of SSN: Cell/Work: Address: Please check one: Unmarried Married Separated Widowed Divorced Gender: (0) Female (1) Male Ethnicity: (0) (b) Non-Hispanic (1) (a) Hispanic Date of Birth: Age: # in Household: # of Dependents in Household: Race: (a)(0)american Indian/Alaskan Native (b)(1)asian (c)(2)black/african American (d)(3)native Hawaiian/Pacific Islander (e)(4)white (f)(5)american Indian/Alaskan AND White (g)(6)asian AND White (h)(7)black/african American AND White (i)(8)american Indian/Alaska Native AND Black/African American (j)(9)other (k)(10)chose not to respond Please Check All That Apply: Single Head of Household Female Head of Household First Time Home Buyer US Veteran Owned a home in Last 3 Years Disabled Citizenship: US Citizen Permanent Resident Non-Resident Household Annual Income: $ For Housing Counselor to complete: HH # AMI % How did you hear about us? Housing Information Do you own or rent? How long have you lived at this address? Are you working with a credit counseling agency? yes no Agency Name: 2 P a g e

3 NET Salary NET Salary Social Security Other: Other: TOTAL INCOME Incomes Type Housing Rent or 1st mortgage 2nd mortgage/line of credit on house HOA Property insurance Property taxes Home repairs/maintenance Utilities Electric & Gas Water Trash Home phone Cell phone Internet Transportation Auto loan(s) Auto insurance Gas Maintenance and repairs Tags Public transportation Food Groceries Dining Out Personal Items Clothes Dry cleaning Haircuts Personal care: nails, toiletries, etc Medical Medical insurance Doctor co-pays Prescriptions Dentist Glasses Medical bills Donations Religious/Charity Monthly Budget Amount TOTAL INCOME TOTAL EXPENSES SURPLUS/SHORTFALL Expenses Type Amount Type Amount Children Child Care Child support payments Activities School lunches Other Entertainment Cable Gifts Hobbies Gym Travel Beer, wine, liquor Cigarettes Movies, sports, concerts, museums Subscriptions Education Tuition, books, lessons Pets Food Vet Insurance Disability Insurance Life Insurance Debts Taxes Credit Card Credit Card Credit Card Collections Collections Personal loan Student loan Payday loan Savings Savings account TOTAL EXPENSES 3 P a g e

4 Verification of Lawful Presence Pursuant to 8 U.S.C and C.R.S , et seq Step 1 The applicant must present (check one): A Colorado driver s license or Colorado identification card A United States military card or military dependent s identification card United States Coast Guard Merchant Mariner card Step 2 The applicant has presented (check one): A U.S. Passport (# ) A qualifying birth certificate* None of the above If the applicant cannot provide a U.S. Passport or qualifying birth certificate, please explain why below: * Qualifying birth certificates include, with limitation: the 50 states of the United States, the District of Columbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, Swain s Island or the Northern Mariana Islands. Step 3 Affidavit of Lawful Presence I,, swear or affirm under penalty of perjury under the laws of the United States and of the State of Colorado that (check one): I am a United States citizen, or I am a Legal Permanent Resident of the United States, or I am lawfully present in the United States pursuant to Federal law, as defined in 8 U.S.C. 1641** I understand that this sworn statement is required by law because I have applied for a public benefit from the Boulder County Housing Authority. I understand that State and Federal law require me to provide proof that I am lawfully present in the United States prior to receipt of this benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute Signature Name (Print) Date ** Including, with limitation: Aliens lawfully admitted for permanent residence under the Immigration and Nationality Act ( INA ), 8 USC 1101 et seq.; Refugees, admitted under 207 of the INA; Aliens granted asylum under 208 of the INA; Cuban and Haitian Entrants, as defined in 501(e) of the Refugee Education Assistance Act of 1980; Aliens granted parole for at least one year under 212(d)(5) of the INA; Aliens whose deportation is being withheld under 243(h) of the INA as in effect prior to April 1, 1997 or 241(b)(3) of the INA, as amended; Aliens granted conditional entry under 203(a)(7) of the INA in effect before April 1, 1980; Battered aliens, who meet the conditions set forth in 431(c) of Personal Responsibility and Work Opportunity and Reconciliation Act of 1996, as added by 501 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, P.L (IIRIRA), and amended by 5571 of the Balanced Budget Act of 1997, P.L (BBA), and 1508 of the Violence against Women Act of 2000, P.L Section 431(c) of PRWORA, as amended, is codified at 8 USC 1641(c).1; Victims of a severe form of trafficking, in accordance with 107(b)(1) of the Trafficking Victims Protection Act of 2000, P.L P a g e

5 Housing Counseling Program Disclosure Statement Services. I understand that the Boulder County Housing Counseling Program (BCHCP), a HUD-approved Housing Counseling agency, will provide me with housing counseling services. The Housing Counseling Program provides financial literacy, prepurchase, foreclosure prevention, post-purchase, and reverse mortgage education and counseling. You are not obligated to receive services offered by Boulder County or our partners. Waiver. I hereby agree to hold harmless BCHCP and its agents and/or employees from any and all claims or causes of actions arising, or which may arise, from mistakes, errors, or omissions pursuant to said counseling and/or BCHCP s efforts on my behalf. I acknowledge that BCHCP makes no guarantees with regard to the outcome of these services. Authorization to Release and Receive Information. In order to assist me in my housing needs, I hereby authorize BCHCP to release and receive my personal information and records, including, but not limited to, my name, social security number, income and employment information, credit report, and account information. This authorization shall remain in effect until I revoke it in writing and shall allow BCHCP to release and receive my personal information and records to and from third parties, including, but not limited to, financial institutions, mortgage service providers, governmental entities, affordable housing programs, credit reporting agencies, and any other third parties that BCHCP deems necessary. Confidentiality. Other than as provided herein, BCHCP will make every effort to keep my personal information and records confidential. I understand, however, that BCHCP may be obligated to disclose my personal information and records under the Colorado Open Records Act or other state or federal law. I further understand that, as a grant recipient, BCHCP must comply with various reporting obligations, and I hereby authorize BCHCP to release my personal information and records as required pursuant to these various reporting requirements Servicio: Entiendo que el Programa de Consejería para Vivienda del Condado de Boulder (BCHCP), Agencia de Consejería para Vivienda HUD Aprobada, me proveerá del servicio de consejería para Vivienda. El Programa de Consejería de Vivienda provee literatura financiera, educación para posibles compradores de vivienda, prevención de ventas de Remate, educación y consejería acerca de préstamos reversibles. Ud. no está obligado a recibir los servicios que ofrecen el Condado de Boulder o sus asociados. Exención de responsabilidad: Por la presente acepto eximir de toda responsabilidad a BCHCP y a sus agentes o empleados por cualquiera o todos los reclamos o causas de las acciones surgidas o que puedan surgir por fallas, errores u omisiones procedentes de dicho asesoramiento y/o de los esfuerzos de BCHCP hechos en mi nombre. Reconozco que BCHCP no me da garantías con relación a los resultados de estos servicios. Autorización para dar y recibir información: Con el propósito de asistirme en mis necesidades de Vivienda, por la presente autorizo a BCHCP a dar y recibir mi información personal e historial incluyendo, pero no limitándose, mi nombre, número de seguro social, ingresos, información de empleo, reporte de crédito e información de la cuenta. Esta autorización será efectiva hasta que yo la revoque por medio de un documento escrito y autoriza a BCHCP para dar o recibir mi información personal e historial de y para terceras personas, incluyendo, pero no limitándose, a instituciones financieras, proveedores del servicio de préstamos, entidades gubernamentales, programas de Viviendas de Fácil Accesibilidad, agencias de reporte de crédito y otras entidades de tercera persona que BCHCP considere necesario. Confidencialidad: Con excepción de lo dispuesto anteriormente, BCHCP hará todos los esfuerzos posibles por mantener confidencial mi información personal e historial. Sin embargo, entiendo que BCHCP está obligado a revelar mi información personal e historial según el Open records Act de Colorado u otra ley Estatal o Federal. Comprendo que, como beneficiario de una subvención (grant), BCHCP debe cumplir con ciertas obligaciones en temas de reporte, y por medio de la presente autorizo a BCHCP para divulgar mi información y records personales según sean requeridos para estos reportes. Client: (Printed Name) (Signature) Date Loan Number (if applicable) Social Security Number (last 4 digits) Property Address Housing Counselor, Boulder County Housing & Human Services Date Boulder County Housing and Human Services, Housing Counseling Program PO Box 471, Boulder, CO P a g e

6 How to Obtain a Copy of Your Credit Report and Credit Score Consumers can order a free credit report* at: Online: By phone: By written request: Annual Credit Report Request Service P.O. Box Atlanta, GA *This is a FREE credit report once per year per credit reporting agency. Start in the middle of the page at START HERE and select your state. If you are asked for payment information, back up and start again. There are many opportunities to enroll in other services for fees. This is not part of getting your free credit report. The Federal Trade Commission launched a major credit resource for consumers, providing a centralized location for consumers to obtain a free copy of their credit report once each year from each of the big three credit reporting agencies. With identity theft at epidemic levels, consumers are recommended to take advantage of this resource to make sure there are no problems or discrepancies in their credit report. The website is secure you will be asked for personal information to verify your identity. There is always a cost to obtain your credit score. You may visit each of the websites listed below. Each credit reporting agency has its own fee for providing credit scores. You may also visit to obtain your FICO score. The following are contact information for each individual credit report agency: EXPERIAN EXPERIAN ( ) P.O. Box Allen, TX TRANSUNION LLC Consumer Disclosure Center P.O. Box 1000 Chester, PA EQUIFAX P.O. Box Atlanta, GA P a g e

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